Addressing the noncommunicable disease (NCD) burden in prisons in the WHO European Region - Interventions and policy options
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Addressing the noncommunicable
disease (NCD) burden in prisons
in the WHO European Region
Interventions and policy options
POLICY BRIEF
A
ABSTRACT The aim of this brief is to shed light on the scale of the noncommunicable disease (NCD) burden in prisons and the unique challenges they present for individuals and society both during and following incarceration. The brief also highlights best practices, interventions and policies to address NCDs and their risk factors in the prison context, while also noting special considerations for their implementation in specific contexts and settings. WHO/EURO:2022-4912-44675-63435 KEYWORDS ALCOHOL USE, SMOKING, NUTRITION, EXERCISE, CARDIOVASCULAR HEALTH, NEOPLASMS, EUROPE, HEALTH POLICY, NONCOMMUNICABLE DISEASES, RISK FACTORS, PRISONS © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition: Addressing the noncommunicable disease (NCD) burden in prisons in the WHO European Region: interventions and policy options. Copenhagen: WHO Regional Office for Europe; 2022”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Addressing the noncommunicable disease (NCD) burden in prisons in the WHO European Region: interventions and policy options. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Cover photo: ©UNODC/Maxim Shubovich
Addressing the noncommunicable disease (NCD) burden in prisons in the WHO European Region Interventions and policy options POLICY BRIEF
Contents
Foreword........................................................................................................................................iv
Acknowledgements......................................................................................................................vi
Abbreviations...............................................................................................................................vii
Executive summary..................................................................................................................... viii
Introduction.................................................................................................................................... 1
1. Prevalence of noncommunicable diseases (NCDs) in prisons................................................ 3
2. Profiles of the main NCDs in prisons........................................................................................ 7
2.1 Cardiovascular disease (CVD)...................................................................................................8
2.2 Obesity and overweight..........................................................................................................10
2.3 Cancer.......................................................................................................................................12
2.4 Respiratory conditions............................................................................................................14
2.5 Mental health............................................................................................................................16
3. Risk factors for ill health in prison...........................................................................................19
4. Approaches and policy options to prevent and reduce the NCD burden in prisons............ 23
4.1 Improving nutritional quality and reducing salt intake......................................................... 25
4.2 Increasing physical activity.................................................................................................... 27
4.3 Reducing alcohol use............................................................................................................. 29
4.4 Reducing tobacco use.............................................................................................................31
4.5 Halting the rise in diabetes.................................................................................................... 34
4.6 Halting the rise in obesity and overweight........................................................................... 35
4.7 Reducing high blood pressure............................................................................................... 36
4.8 Cervical cancer screening...................................................................................................... 36
4.9 Environmental interventions.................................................................................................. 37
5. Enabling factors and implementation considerations........................................................... 39
5.1 Enabling factors....................................................................................................................... 39
5.1.1 Health-care workforce................................................................................................... 39
5.1.2 Technologies and medicines........................................................................................ 43
5.1.3 Health surveillance and monitoring............................................................................. 44
5.1.4 Continuity of care.......................................................................................................... 45
5.2 Implementation principles and considerations.................................................................... 48
6. Conclusions..............................................................................................................................51
References................................................................................................................................... 53
iii
Foreword
There are more than 1.5 million people held in detention across the 53 countries of the
WHO European Region and over 11 million globally. When a person is deprived of their
freedom, governments become accountable for their rights as citizens and are therefore
responsible for ensuring access to the highest standard of health care, regardless of
a person’s race, religion, political belief, economic and social condition, and legal status.
It is estimated that around 30 million people, most of whom experience multiple
disadvantages, move globally between prisons and communities each year.
The continuous interflow of people between community and custodial settings makes
the latter a key focus of public health, as investments made in prison health services
decrease the burden on community health care and eventually contribute to healthier
societies. Addressing health inequalities in prisons is crucial.
Noncommunicable diseases (NCDs) cause 71% of deaths globally and present a challenge
to health-care systems. However, NCDs are poorly recognized as an important health
issue in prisons, where the main focus has traditionally been on the prevention of infectious
diseases and injuries. There is scarce research into NCDs in prisons or robust surveillance
data from prisons. The underinvestment in NCDs witnessed in society at large is magnified
in prison settings, where NCDs are still not considered a priority.
WHO’s European Programme of Work sets out a vision to better support countries in
achieving universal health coverage. One of its flagships is mental health, an important
component of prison health. Current information systems in the European Region, however,
iv
poorly capture the full remit of service delivery and health outcomes. Information on
behavioural risk factors captured in prison health records is also scarce. Previous data
from the Health in Prisons European Database suggested that only 2% of the Region’s
Member States had data on the proportion of overweight people in prison and only
15% could indicate the prevalence of hypertension – both risk factors for NCDs. This is why
WHO believes that it is a priority for prison health systems to focus on full implementation
of prison health records. Information systems need to capture high-quality data on NCD
risk factors so that evidence-based policies can be adopted.
Since the start of the COVID-19 pandemic, there have been numerous outbreaks
in prisons, often as a result of inadequate capacity and inequalities in access to
resources. Existing NCDs put those affected at increased risk of serious illness or
death. Over 90% of imprisoned people are male, the age profile is rising, and there is
an overrepresentation of black and ethnic minority groups. As with NCDs, the most
marginalized groups are worst affected by COVID-19. This last year has shown us that
many of the tools required to fight a pandemic are those required to fight NCDs.
By launching this report, the WHO Regional Office for Europe expects to contribute to
increased awareness of the burden of NCDs in prisons and to demonstrate the need to
invest in efficient health information systems that capture data on NCD risk factors and
so allow prison health and public health to become fully integrated.
Dr Hans Henri P. Kluge
WHO Regional Director for Europe
v
Acknowledgements
This publication was developed by Filipa Alves da Costa, Public Health Specialist,
WHO European Office for the Prevention and Control of Noncommunicable Diseases,
under the guidance of Carina Ferreira-Borges, Acting Director for Noncommunicable
Diseases, Division of Country Health Programmes, and Programme Manager, Alcohol,
Illicit Drugs and Prison Health, WHO Regional Office for Europe.
This document received important contributions, in terms of structure and content, from
Yanina Andersen, Public Health Specialist, WHO European Office for the Prevention and
Control of Noncommunicable Diseases; Sunita Stürup-Toft, Public Health Specialist, Public
Health England, United Kingdom; and Emily Wang, Professor, Yale School of Medicine,
and Director of SEICHE Center for Health and Justice.
The final document received contributions from Sofia Ribeiro, public health physician;
Tammy Boyce, Health Inequalities Specialist; Angela Ciobanu, Technical Officer, Tobacco
Control Programme; Romeu Mendes, public health physician; Stephen Whiting, Technical
Officer, Physical Activity Programme, WHO European Office for the Prevention and Control
of Noncommunicable Diseases; Maria Neufeld, Technical Officer, Alcohol and Illicit Drugs
Programme; Marilys Corbex, Senior Technical Officer, Cancer, Division of Country Health
Programmes.
The publication was made possible by funding from the Government of Finland.
vi
Abbreviations
ACA Affordable Care Act (USA)
COPD chronic obstructive pulmonary disease
CVD cardiovascular disease
HIPED Health in Prisons European Database
NCD noncommunicable disease
SDG Sustainable Development Goal
viiExecutive summary
This report summarizes the existing evidence and presents policies and interventions to
reduce the noncommunicable disease (NCD) burden in prisons, providing examples of
good practice from across the world. While not exhaustive, these examples are expected
to offer simple and well-designed practice-based solutions that will increase physical
activity, improve nutritional quality and reduce salt intake, reduce alcohol and tobacco
use, halt the rise in diabetes, halt the rise in obesity, reduce high blood pressure, extend
cervical screening and improve environmental interventions.
Finally, some enabling factors that should enhance successful implementation are
presented; these relate to the health workforce, technologies and medicines, health
surveillance and monitoring, and continuity of care.
In accordance with the principle of equitable standards of care, NCD policies in prisons
should reflect and align with WHO global approaches to NCDs, while also taking account
of the specificities of prison settings with respect to both design and implementation of
interventions and policies. Successful achievement of NCD targets in prisons requires
that the NCD risk factors that present particular challenges in prisons are addressed.
Key governance principles include the principles of equivalence of care between
prison and community, and clinical independence of health-care providers. Clinical
independence is important in a context where the principles of free choice of provider
may not apply and is considered a critical aspect of high-quality care. Continuity of care
and sustainability of interventions are also important aspects of good NCD policies in
the criminal justice system. Therapies should be available and free of charge during
incarceration, but action is needed to ensure that access to continuous care is sustained
following release.
viiiThere is scarce high-quality evidence on the prevalence of NCDs in prisons.
The existing body of literature suggests that, for most NCDs, there is
an excess prevalence in prison.
X3
Cardiovascular disease Obesity and overweight
(CVD) Overweight and obesity were found
Prevalence of CVD in individuals aged to be only slightly higher in prison
over 50 living in prisons in Europe is populations, with some inconsistencies
over three times higher than that across studies. However, various
reported for the general population. studies suggest that many people gain
excess weight while in prison and that
weight-related health problems are
common in correctional settings.
X 1.4–1.6
X6
Cancer
Most evidence on cancer risk
originates from the USA and Canada
and suggests that incarcerated Respiratory conditions
individuals have a 4–5 times higher The chances of having respiratory
risk of reporting cervical cancer and a conditions, including asthma and
1.4–1.6 times higher risk of dying from chronic obstructive pulmonary
cancer, particularly of the head and disease, have been reported to be
neck, liver, and lung, than people of the 3–6 times higher in prison compared
same sex and equivalent age living in to the general population.
the outside community.
Mental health
People in prison have rates of psychotic illnesses
and major depression 2–4 times higher, and rates
of antisocial personality disorder 10 times higher, X 2–4
than the general population.
ixx ©WHO/Jerome Flayosc
Introduction
The burden of noncommunicable diseases (NCDs) presents an enormous challenge for
the prison population and system. Studies have shown that several NCD conditions,
including cardiovascular disease (CVD) and cancer, are among the most common causes
of death in prisons (1,2).1This situation is further exacerbated by the poor pre-existing
health condition of people living in prisons, who often come from disadvantaged and
discriminated groups of society and for whom prison may be their first contact with health
services. Additional risk factors such as alcohol consumption, smoking, lack of physical
activity and unbalanced nutrition, which are either unique to or amplified in the prison
environment, further increase the severity of health outcomes.
Many commitments have been made, at global, regional and country level, to address the
overall NCD burden in the general population. The WHO framework action plan outlines
a group of targets and indicators to help Member States meet their NCD challenges (3).
Despite the scale of the burden that NCDs impose on prisons and the broader attention
that the issue commands in the public health community, it remains largely unaddressed
in the prison context. The importance of addressing the problem is clear in the WHO
Global Programme of Work (GPW13), which sets the target that by 2023 one billion more
people should benefit from universal health coverage – a goal that is only possible if no
one is left behind, including those in detention (4).
Principle 9 of the United Nations Basic Principles for the Treatment of Prisoners states
that “Prisoners shall have access to the health services available in the country without
discrimination on the grounds of their legal situation”(5), an argument that is reinforced
in the Moscow Declaration on Prison Health as Part of Public Health, with the notion that
governments become accountable for meeting, free of charge, all the health-care needs
of people deprived of liberty (6). Equivalence of care is also emphasized by the United
Nations Principles of Medical Ethics, which states that health personnel, particularly
physicians, charged with the medical care of prisoners and detainees have a duty to
provide them with protection of their physical and mental health and treatment of disease
of the same quality and standard as is afforded to those who are not imprisoned or
detained (7,8). Independence of care from the prison administration is also a crucial aspect
of the quality of health care, implying that health-care personnel must have total autonomy
in their decisions, which should never be overruled by security issues (9). However, most
people do not stay in prison indefinitely and often the period of incarceration is relatively
short, particularly in the WHO European Region. Health care delivered to people in
detention must therefore be recognized as part of a pathway to and from community
health services, as stressed in the Helsinki Conclusions (10).
This brief aims to show the scale of the NCD burden in prisons and the unique challenges
it poses in the prison context. It outlines the available evidence on the best practices and
policies that have been implemented and claimed to have a positive impact on addressing
NCDs and their risk factors in prisons. In addition to presenting possible interventions,
the brief includes considerations for implementation in specific contexts and settings.
12 ©WHO/Atul Loke
1
Prevalence of NCDs in prisons
The disproportionate burden of NCDs in prisons is well documented. A systematic review
and meta-analysis of 28 NCDs from prisons in 11 countries showed pooled prevalence
for the most significant NCDs ranging from 8% for cancer to 39% for hypertension (11).
Another study, from the United States of America, reported a higher likelihood of several
chronic conditions among people living in prisons compared to the general population,
including a five times higher chance of cervical cancer and 1.2 times higher chance of
hypertension (12). A cohort study in Canadian prisons identified a mean age of death of
48 years; the most common causes of death were cancer and ischaemic heart disease,
accounting for 15% and 10% of deaths, respectively (13).
While it has been suggested that the effects of incarceration on some NCDs, such as
CVDs, result from pre-existing factors including demographic characteristics, ethnicity
and low socioeconomic status, some conditions may be related to the prison environment
itself or exacerbated during incarceration. For instance, among people in prisons in the
USA with an active medical problem, one study found that 24% of people living in state
prisons who were taking prescription medication stopped taking their medication during
incarceration and only 6% had undergone required laboratory monitoring (14). This can be
attributed to several factors, including the kind of health care provided in prison (where,
for instance, clinical independence and equivalence in access to specialized medical
care may be lacking); the prison environment (including issues such as unhealthy diets or
limited exercise); and limited autonomy to exercise positive heath behaviours (such as the
ability to manage one’s own medication or to have control over exercise opportunities) (2).
3An increasing and ageing prison population presents additional challenges to a population
that already experiences worse health outcomes. In 2018 there were more than 11 million
people living in prison around the world, representing an increase of 8% since 2010 (15).
Of these, around 1.5 million were imprisoned in Europe. Because the prison population is
growing and changing, increasing numbers of older individuals are more likely to experience
NCDs (16). It has also been reported that ageing per se, occurring globally, is playing a
role in the age profile of the prison population and, consequently, in disease prevalence.
A systematic review focusing on epidemiological data of people in prison highlighted that
older individuals had higher rates of diabetes, cancer, CVD and liver disease (17). It is worth
noting that, while in industrialized countries and in the WHO European Region people
aged 65 and over are conventionally referred to as “elderly”, it has been shown that, for
the prison population, a definition of 50 years and over might be more appropriate (14,18).
Furthermore, individuals with a history of incarceration have been shown to have higher
rates of comorbid alcohol and drug use disorders and mental disorders, compared with
the general population, making treatment harder to manage (13). Vulnerability to NCDs
is particularly pronounced among certain demographic groups. It has been reported that
women with a history of incarceration have a higher risk than men of multiple chronic
diseases (19).
The poor health of people living in prisons has direct implications that extend beyond the
time actually spent in prison, as care following release is an important aspect of good
NCD care. When individuals are released from a correctional facility, their health outcomes
are generally worse, compared with people who have never been incarcerated, because
they have fewer economic resources, higher levels of stress, competing priorities and
poor access to care (18). National studies conducted in the USA prior to the expansion
of Medicaid* under the Affordable Care Act (ACA) show that only 20% of individuals
were insured following release from a correctional facility and saw a health-care provider
for routine care within a year following release (20). Other publications show that the
expansion under the ACA saw a 6% decrease in the proportion of uninsured people among
those with no history of incarceration and a 7% decrease among those with a history of
incarceration. However, the difference in coverage between these two population subsets
(justice-involved individuals and the general population) persisted and remained at around
16%, with the proportion of uninsured among those with a history of incarceration falling
from around 40% to 35% following the advent of the ACA, compared with a fall of 25%
to 20% among those with no such history (21). Nonetheless, this study also suggests
that, even though the gain in coverage was slightly higher for those involved with the
criminal justice system, there was no comparable increase in engagement with health-
care services. It has been reported that beneficiaries of Medicare* who have recently
* Medicaid is a state and federal health insurance programme for adults who fall under the federal poverty line; it is
the main insurance scheme that would cover most people released from prison. However, it is possible that some
individuals may, alternatively or in addition, be covered by Medicare, which is a health insurance that covers people
aged 65 and some younger people who have disability status or conditions such as end stage renal disease.
4been released from correctional facilities have a higher hospitalization rate from cancer
and CVD and an increased risk of mortality in the months following release, compared
with the general population (22). Two statewide studies in Washington State and North
Carolina and one focused on HIV individuals also found an increased risk of cancer
mortality in the year following release among released individuals compared with the
general population (12,23). Increased risk of developing hypertension and left ventricular
hypertrophy and higher rates of inadequate hypertension management and control have
been reported, as well as an increase in all-cause mortality among white men with a history
of incarceration (24,25).
56 ©WHO
2
Profiles of the main NCDs
in prisons
In the countries of the WHO European Region, governance of prison health is most
commonly held by the Ministry of Justice, sometimes by the Ministry of the Interior, and
in a minority of cases by the Ministry of Health. Moreover, even in those countries where
the Ministry of Health is involved, prison health information is not integrated with public
health. The level of digitalization of health records is variable but tends to be suboptimal.
For all these reasons, data and evidence are a challenge in this area, and prevalence
estimates often result from ad-hoc academic research studies. Definitions and criteria
used for defining populations, diseases and risk factors for ill health differ across studies,
limiting comparisons within and across countries.
Because the literature on NCDs and their risk factors in the imprisoned population is
scarce, for this brief no limits were imposed on date of publication or study type.
While there is a wide range of NCDs, in this section the focus is on five main NCDs,
four of which account for almost 70% of deaths worldwide (26). These include CVDs
(including heart disease and stroke), cancer, diabetes and respiratory conditions (notably,
chronic lung disease). The fifth NCD is mental health, the role of which in achieving global
development goals is increasingly acknowledged (27).
72.1 CVD
Pooled prevalence among 93 862
individuals aged over 50 living in
prisons in 11 countries suggests
that 38% present a CVD (11). 12%
38%
In the general population, in 2015 there
were over 85 million people living with
CVD (equivalent to around 12% of the
European population)(28).
CVD is one of the leading causes of death among incarcerated individuals (29),
and those recently released have a higher risk of dying from CVD compared to
the general population (2).
Low socioeconomic status is a known
predictor of poor cardiovascular health,
often related to engagement in unhealthy
lifestyles such as frequent fast-food
People in prison have higher rates consumption – habits that may persist
of CVD risk factors, especially during incarceration in countries where
hypertension and smoking, such options exist in prison facilities.
compared with demographically
matched individuals living
in the community (2,30).
839% 37%
It has been estimated that 39% In the general population,
of the prison population present age-standardized prevalence of
with hypertension (11). hypertension in 2019 reported for the
WHO European Region was 37% (31).
Among females living in Brazilian An existing cohort in the USA –
prisons the reported prevalence of Coronary Artery Risk Development in
hypertension is 38% (32). Young Adults (CARDIA), developed
to explore the links between
imprisonment and cardiovascular
health – showed that former inmates
Other estimates indicate
had a 1.7 times higher risk of having
hypertension may range between
hypertension, even after adjusting for
10% and 30% (2,23,33). Nonetheless
known risk factors, such as smoking,
(in this case, based on the USA
alcohol and illicit drug use, and
only), this value is around 1.7 times
family income (24).
higher than that reported for the
general population. Most of the
prison population is male and most
studies therefore present estimates Similar findings were reported by
for males. others, also in the USA, who found
that the likelihood of developing
hypertension was 1.2 times higher
among people living in prison (12).
Ethnicity is associated with
hypertension. Black populations
have an earlier onset compared In 2014 diabetes remained one of the
to white populations, both in main CVD risk factors in Africa (36).
prison and in the community (34). While the estimated prevalence
There is also evidence that rates of diabetes for the region in 2011
of incarceration are higher among was 4% (37), evidence suggests that
black populations (35). Thus it is the prevalence of diabetes in people
expected that the excess proportion living in prison in Africa was more than
of black people in prison contributes twice as high (9%) (38). These data
to the excess prevalence of suggest that ethnicity has a role in
hypertension in prison. addition to inequalities.
92.2 Obesity and overweight
In Italy the prevalence of obesity and overweight among people in detention (67%) was
found to be higher than in the general population (55%) (39).
67% 55%
US-based studies point to higher Similar values were reported in other
values, with obesity (including severe studies that related exclusively to
obesity) and overweight comprising women (70%), although in the USA
74% of the prison population (2). they did not differ from those found
in the general population (40).
A systematic review covering 24 311 males aged between 16 and 81 living in prison
suggested that the prevalence of obesity was between 8% and 56% (41). This variability
may be explained by the origin of the primary studies (most were from developed
countries), the reporting methods used (many used self-reported data), the varied sample
sizes, and the time of measurement with respect to length of incarceration.
24%
Evidence from the United Kingdom points to
a prevalence of obesity at admission of 16%,
rising to 24% six months after incarceration (42).
16%
10Data from a systematic review including
11 studies reported an average weight
0.2 kg 0.2 kg 0.2 kg
gain of 0.2 kg (0.43 lb) per week
following incarceration (43). 0.2 kg 0.2 kg 0.2 kg
Comparing obesity at admission and during
3% incarceration, a French study found an increase in
prevalence of 3%, suggesting the negative impact of
incarceration. This study, albeit small, also suggested
that females are more prone to exhibit abdominal
obesity, to have low physical activity and to be
diagnosed with eating disorders (44).
Existing knowledge suggests that many people gain excessive weight while in prison
and that weight-related health problems are common in correctional settings (45).
87%
Eating disorders are highly prevalent in women living
in prison in high-income countries; these may lead to
them having overweight and obesity or underweight,
thereby undermining physical and mental health (45). 68% 77%
A study in a female prison showed a very high prevalence
of daily consumption of ultra-processed foods, including
hot-dog bread (87%), sweetened beverages (68%)
and sweets/candies (77%) (46).
Evidence from 2006 suggested that nutritional practices
among people living in prisons were poor, with frequent low
fruit and vegetable consumption. However, such data also
suggested that, even when people in prison were given the
opportunity to access a healthy diet, they often chose not
to, indicating that the design of interventions needed to
be improved (47).
112.3 Cancer
Individuals incarcerated in US jails and
prisons have higher rates of cancer
compared with the general population (12).
Estimates suggest that the risk of reporting
cervical cancer in jails and prisons may be
4–5 TIMES
4–5 times higher (12). HIGHER
A study focusing on prevalence of cancers
that are substance use-related (related to
smoking or alcohol use) and can be detected
with guideline-based screening (lung, cervical,
colon, breast, prostate) used 10 years of data
from the US National Survey on Drug Use and
2% 5%
Health; compared with individuals without
criminal justice involvement, it was found
that those with criminal justice involvement
2% had a 2% higher age-adjusted prevalence
of lung cancer; a 5% higher prevalence of
cervical cancer; and a 2% higher prevalence
of alcohol-related cancer (48).
Furthermore, people in prison in Ontario, Canada, were reported to have a
1.4–1.6 times higher risk of dying from cancer, particularly head and neck, liver and
lung, than people of the same sex and equivalent age living in the community (49).
Higher cancer mortality among those living in US jails and prisons had previously
been reported, with 31% of prison deaths in 2013 being cancer-related (29).
12There are a number of possible reasons
why cancer mortality may be associated
with incarceration. Individuals with
a history of incarceration more commonly
display cancer risk factors such as
smoking and alcohol use (48), and present
with infectious diseases, including HIV
and hepatitis C (50–52).
Evidence shows that, in the USA, Another study, from Canada,
incarcerated patients present at focusing on screening for cervical
a later stage for all cancer types cancer, reported that women
compared with the nonincarcerated experiencing imprisonment were
population. In particular, later stages of less likely to be up to date with
diagnosis were identified for colorectal, screening. The study reported
oropharyngeal, lung and skin cancers that 54% of women in prison were
and screenable cancers (colorectal, overdue for screening, compared to
prostate, lung) as a whole (53). 53
33% in the general population (20).
While screening and treatment for cancer may be
constitutionally guaranteed in correctional facilities in
some countries, access to good-quality services may
be worse for individuals in correctional facilities than
in the community. Screening is the only cost–effective
intervention – it should be recommended to all countries
of the WHO European Region and prisons should
not be excluded.
If cancer is not diagnosed at early
stages in those living in prison, there
will be worse treatment outcomes.
132.4 Respiratory conditions
Incarcerated individuals have been reported to have a higher chance of
respiratory conditions, including asthma (12). In one study, respiratory
disease was the second most common self-reported condition in prison,
reported by 17% of individuals assessed (23). In the general population,
asthma prevalence was estimated to be around 5% in 2015 (54).
5% 17%
One study looking at individuals newly admitted to a maximum-security
jail reported that respiratory conditions were the most frequently
encountered, with a value as high as 34%. This study confirmed
that smoking habits were frequently associated with asthma (55).
34%
14Chronic obstructive
3% 4–18%
pulmonary disease (COPD)
in those aged over 50 has
been reported as ranging
from 4% to 18% in prison (11),
compared to 3% found in
the general population (20).
A field study in Greece reported COPD
to be present among 6% of inmates,
6%
increasing with age and length of
sentence. Not surprisingly, this same
study also showed that 79% of these
individuals had marked smoking
habits with intense associated
nicotine dependence (57).
152.5 Mental health
Mental health is a public health challenge Psychotic illness and major depression
in prisons across the world. People in
prison have rates of psychotic illnesses
and major depression two to four times 2-4 TIMES
HIGHER
higher than the general population, and
rates of antisocial personality disorder
about 10 times higher (58).
LMIC
A recent systematic review involving over
14 500 people in prison from low- and
middle-income countries suggested a
prevalence of 6.2% for psychosis and 16% for
Major depression Psychosis
major depression. Compared to the general
population, these values are up to 16 times 6 TIMES 16 TIMES
HIGHER HIGHER
higher for psychosis and up to six times
higher for major depression (59).
A study involving over 1000 females living in prison,
assessing mental health through a standardized
questionnaire, reported a prevalence of common
mental disorders of 67%. This study suggested
that such disorders were associated with lack
of income, physical inactivity and psychological
violence (60).
A meta-analysis conducted in the general population estimated the lifetime
prevalence of common mental health disorders to be 29% (61). Estimates should be
interpreted cautiously and comparisons across studies limited not only by settings but
also by the methods and tools used to assess mental health and by the classifications
used (for example, types of depression and self-reported versus clinical).
1684%
Women have been reported to be more likely than men to have a preliminary
diagnosis of mood disorders in prisons (62). A study conducted to investigate mental
health disorders among women living in prisons found a much higher likelihood of
a diagnosis, with 84% of women meeting the criteria for a mental health disorder;
the most common were drug use disorder (57%), major depression (44%) and
post-traumatic stress disorder (36%) (63).
A study undertaken among older
Another study, of women in
females in prison suggested
the Canadian prison system,
that there were high numbers of
reported that substance use
mental health conditions, including
disorders (91%) and affective
depression and anxiety. Half of
disorders (42%) were the
these women reported a history
most prevalent mental health
of sexual or physical abuse, with
diagnoses, which in most
many cases leading to serious
cases co-occurred (64).
trauma and physical injuries (65).
Mental health problems, particularly anxiety, depression and suicidal desire,
were also commonly found among older people in prison (17).
As a result of all these issues, suicide accounts for
50% of all prison deaths (66). Suicide rates have also
been shown to vary markedly according to sex, similar to
50%
the pattern observed in the outside community but with
a considerably higher imbalance. Suicide was reported
SUICIDE
SUICIDE
to be three times higher in males living in prisons and
nine times higher in females living in prisons, when
compared to the general population (67).
1718 ©WHO/Sergey Volkov
3
Risk factors for ill health in
prison
For several decades WHO has focused its attention on four major risk factors that are
shared by most NCDs, including tobacco and alcohol use, low levels of physical activity
and unbalanced diet. More recently, environmental pollution and other environmental
risks have been highlighted as a cause of concern, as they are estimated to be currently
responsible for nearly a quarter of deaths (68). In addition, there are other risk factors
that are typically applicable to certain NCDs, as is the case with drug use, which has a
particular impact on mental health and behaviour. The overlap and interplay between
multiple risk factors are common, suggesting that interventions should target multiple
risk factors in order to affect multiple NCDs simultaneously (68). A graphic representation
of the major risk factors in prisons and other places of detention is presented in Fig. 1.
19Fig. 1. The five major NCD risk factors that are most significant
in prisons and other places of detention
Tobacco Alcohol
Smoking prevalence in prisons The prevalence of alcohol use
was found to be over 50%, more disorders is known to be considerably
than twice as high as in the general higher in the prison population than
population (12). in the general population (70). Using
standardized measures, prevalence of
alcohol use disorders as high as 73%
has been reported, including 36% with
possible dependence (71).
Unbalanced diet
Food in prison has been reported to
contain twice the recommended level
of salt in diets (45). A systematic
review in 15 countries found that
sodium intake in prison was 2–3 times
Lack of physical activity
Only 34% of women in prison and 48%
higher than the recommended
of men reported any physical activity in
level (72).
the previous 24 hours (72).
One study showed a decrease in
walking activity of around 5 km per day
after incarceration (73).
Environment, including
injury and violence
Individuals in detention settings
are disproportionately affected by
violence; at the same time, violence Systemic factors
in prisons often remains clandestine The quality of care provided in prisons
and is not reported (74). can vary significantly and may be
worse compared to the community.
A study focusing on the causes of In one study, only 41% of women
death during incarceration reported aged 40 and older reported having
that 38% were attributable to injury had a mammogram within 2 years;
and poisoning, including overdose, and only 31% of individuals older than
suicide and self-inflicted injury.13 50 reported having a colonoscopy
(49). Shortages of medical staff,
including critical staff such as nurses,
are also common in prisons.
2021
22 ©UNODC/Maxim Shubovich
4
Approaches and policy
options to prevent and reduce
the NCD burden in prisons
Global efforts to reduce NCDs are guided by the WHO Global Monitoring Framework,
which gives direction to Member States so that they can align their national responses
around core areas and specific indicators and targets to measure progress in each
indicator (Fig. 2) (75).
In accordance with the principle of equivalence, NCD policy options in prisons should
align with the global approaches to NCDs while taking account of the specificities of
the prison setting, both in regard to the design of interventions and policies and to their
implementation. Successful achievement of the above-noted NCD targets in prisons
involves addressing the NCD risk factors that, while shared with the general population,
present unique challenges in prisons.
Interventions to prevent and manage NCDs in prison aim to tackle behavioural risk factors,
such as nutrition and physical activity, alcohol and tobacco use. However, interventions
must also consider access to treatment, which may be focused on control of underlying
conditions, such as hypertension and diabetes, or access to pharmacological interventions
and other technologies necessary for secondary prevention of NCDs.
23Fig. 2 presents nine voluntary targets set by the Global Monitoring Framework to be
met by 2025 (75). Six of these targets are subsequently described in detail in sections
4.1–4.7 below; the two targets coloured pink are discussed in section 5.1.2. Premature
mortality from NCDs is a key overarching target, although one that is not fully elaborated
for the prison context given the scarcity of high-quality data. These targets have been
set for the general community and are not specifically tailored to the needs of the prison
population. However, all available evidence indicates that targets set for prisons should
be equivalent to or exceed those set for the general population.
Fig. 2. Nine voluntary targets set for 2025 in the Global
Monitoring Framework
Premature mortality from NCDs
25% reduction
Harmful use of alcohol Essential NCD medicines and
technologies
10% reduction
80% coverage
Physical inactivity Drug therapy and counselling
10% reduction 50% coverage
Salt/sodium intake Diabetes/obesity
30% reduction 0% increase
Tobacco use Raised blood pressure
30% reduction 25% reduction
Mortality and morbidity Risk factors for NCDs National systems response
244.1 Improving nutritional quality
and reducing salt intake
WHO target: 30% reduction (of salt intake)
Supporting good nutritional habits by promoting consumption of fruits and vegetables,
while limiting intake of salt, free sugars and certain types of fat, can enhance the quality
of life of people living in prisons and prevent various NCDs.
Prison food systems include food service catering programmes, self-cook facilities,
prison shops or canteens, food shared with visitors, vegetable gardens and informal
preparation of food in housing units (45). According to data from a survey undertaken
by the WHO Regional Office for Europe, 97% of 37 countries reporting data stated that
meals were prepared in centralized kitchens, while 33% stated that self-cook kitchens
were available (76). Innovative ways of promoting good eating behaviours, such as the
Danish self-catering model, have also been described (Box 1). Other innovative methods
include nutritional education, gardening, inclusion of healthy choices in the prison shop
inventory and culinary training (45).
25Box 1. The Danish prison self-catering model (77)
The Danish self-catering model incorporates several key components,
including normalizing preparation and consumption of meals, to ensure
closer alignment with the community way of living. Initially launched
in 1976, and since then expanded to a nationwide programme, its key
objectives include equipping people with the necessary skills to maintain
a healthy lifestyle during and beyond their sentence. Around 65% of
Danish people living in prison are involved in the self-catering model.
In the absence of cafeterias in Danish prisons, the key activities of this
model include purchasing of ingredients in the prison grocery store,
preparation of one’s own food in self-catering kitchens and cleaning.
A weekly allowance of €67 is paid for groceries and cleaning supplies.
In-cell refrigerators are available to store ingredients purchased.
Although initially conceived as a way to address nutritional problems
in prisons, it is now also perceived as an interdisciplinary initiative to
address health and criminal justice issues to ensure successful transition
post release to reduce the risk of reoffending. Denmark’s reoffending
rate, at 29%, is currently one of the lowest in Europe.
A study evaluating the introduction of a nutritional programme in a Spanish prison found
that there were diet modifications in the vast majority of people, with notable reductions
in weight and blood pressure, leading to a lower CVD risk (78).
The quality and variety of food in prisons depend not only on policy options taken to
promote the adoption of healthy lifestyles but also on the daily food allowance set by
prison administrations, which obviously varies between and within countries (47).
264.2 Increasing physical activity
WHO target: 10% reduction in physical inactivity by 2025 and 15% by 2030 (79)
The Nelson Mandela Rules refer to giving all people living in prison opportunities for sport
and exercise with at least one hour per day of outdoor physical activity, preferably with
technical supervision (80). However, prison regimes have been identified as a potential
barrier to implementing changes in dietary or physical activity behaviour. In some countries
the prison regime itself may limit the potential for behaviour change – for instance,
there may be limited access to prison physical activity infrastructures or limited options
on prison menus. In the United Kingdom, it was reported that 43% of people living in
prisons participated in some form of organized physical education activities, although
wide variations within the country were acknowledged, some of them resulting from the
conditions offered by facilities, such as the availability of a gym or the existence of enough
correctional staff to monitor such activities (47). Other studies suggest that activity levels
can vary widely between countries; for instance, in Australia prison was identified as an
environment with an increased level of physical activity, while in the United Kingdom it was
associated with a decreased level of activity (72). Various initiatives and good practices
have been introduced in different countries to encourage people living in prisons to adopt
a healthier attitude to physical activity (Box 2).
27Box 2. Physical activity – good practice
examples
In Spain a football programme was implemented in 21 prisons
by the Real Madrid Foundation’s Social Sports Programme (81).
Participants reported that the programme had a positive effect on
their life in prison and might encourage them to continue playing
sport after release.
In Australia a popular community-based running programme
– parkrun – has been introduced in prisons (82). People living in
prisons volunteer to organize and run the event for other detainees
and staff, whose family and friends can also be invited. As a weekly
activity, parkrun has been described as a good example of a
strong rehabilitative programme, and participants report a positive
influence on their diet and other lifestyle choices.
There is a lack of literature examining the effects of increased physical activity in prison
settings. One programme designed and led by women living in prisons resulted in reduction
of weight, body mass index and waist–hip ratio, alongside improved energy, sleep and
stress levels; other reported benefits included “having fun” (83). A systematic review of
prison-based exercise training programmes found that 10 out of the 11 studies identified
reported significant changes in physical and mental health-related variables (84).
Such examples support the idea that, if people living in prisons are given the opportunity
to increase their physical activity, there will generally be short- and long-term benefits,
affecting their life choices both in prison and following release. Therefore, the interventions
that are developed will need to help people in prison to consider both immediate changes
that are feasible in the current prison setting and longer-term changes that may be
sustained upon release from prison.
284.3 Reducing alcohol use
WHO target: 10% reduction in the harmful use of alcohol
Harmful use of alcohol was introduced as a concept in the process of developing the
WHO global strategy on alcohol, with the intention of defining the scope and targets for
public health interventions; it is broadly defined as drinking that causes detrimental health
and social consequences for the drinker, the people around the drinker and society at
large. A 10% reduction target in the harmful use of alcohol has been included in the global
voluntary reduction targets and in various national action plans. However, with evolving
evidence that any alcohol poses a health risk – from the first drink – the concept of harmful
use is increasingly being questioned.
Availability of alcohol in prison is regulated in most countries. This includes the regulation
of alcoholic beverages coming into prisons, including via visitors and staff, and explicit
bans on the production of unrecorded alcohol inside prisons. In the prison context,
unrecorded alcohol mainly denotes homemade alcohol brewed by inmates, often under
unsanitary conditions; it also includes alcohol-based products not intended for human
consumption, such as hand sanitizer and mouthwash. Ingestion of these unrecorded
products is particularly risky because they often contain high levels of ethanol, far
exceeding the typical alcohol content of alcoholic beverages, which can result in deep
intoxication and potentially death. The increased demand for hand sanitizers during the
COVID-19 pandemic poses additional challenges since many prisons restrict access
to alcohol-based hand sanitizer (85). Although official data are very limited, evidence
suggests that about half of all the alcohol seized in prisons is unrecorded, and in some
countries there was an increase in seizures of homemade alcohol in prisons during
COVID-19 lockdowns (86).
WHO has issued guidance stating that the prison setting is an opportunity to detect and
treat individuals who have alcohol use disorders, which may or may not be linked directly
to their offences; this is especially important because these individuals are often, in other
situations, labelled “hard to reach” (87).
29A systematic review focusing on interventions during imprisonment identified some
studies where motivational interviewing had a positive impact on people with alcohol
use disorders (88–90). Therapeutic communities have been recognized for reducing
recidivism, lowering substance use in prison and, to a lesser extent, after release (91–92).
An innovative programme to reduce recidivism in New Zealand prisons has been reported
(Box 3). There are, however, reports suggesting that few people receive treatment for
drug or alcohol use disorders while in prison and that opportunities for prison-based
intervention are often missed (93,94).
Box 3. New Zealand programme for alcohol
dependence (95)
In New Zealand an innovative programme for alcohol dependence has
been developed, involving local staff from Public Prisons, Psychological
Services and the Community Probation Service. Its main aim is to
reduce recidivism, which is achieved by focusing on recognition of
thoughts, emotions and behaviours present before and during criminal
activity, particularly when precipitated by alcohol use. This is then
accompanied by learning of specific coping skills and intensive lifestyle
and reintegration planning. An obvious component of the programme is
its continuity following discharge, by liaising with community services.
Nevertheless, for problems to be tackled, the first step is to recognize them. Evidence
suggests that there is a lack of standardized measures and methods for screening
alcohol use in prison (76). More emphasis should therefore be put on the implementation
of national standards for screening, including implementation of screening and brief
interventions for alcohol use disorders, as well as continuation of care and treatment
following release (92,96).
304.4 Reducing tobacco use
WHO target: 30% reduction
Several smoking cessation interventions that have proved effective in the general
population have successfully been used in prisons. Cessation programmes in prisons,
including both pharmacological and nonpharmacological interventions, were found to
lead to a reduction in the number of cigarettes smoked per day and an increase in the
probability of quitting smoking while in prison and of abstinence post release (97). Another
systematic review reported that cessation rates were comparable in prisons and in the
community, where strategies employed included a mix of brief behavioural and cognitive
advice sessions, pharmacotherapy and financial incentives (98).
Evidence-based interventions that are effective in the general population can also be
effective in prison and their effects seem to persist over time even following release (99).
However, if access is not equitable, such interventions can worsen inequalities. In some
prisons access to nicotine-replacement therapies may be limited or not free of charge;
unsuccessful smoking cessation programmes in detention settings have been
attributed to the high costs of these therapies (100). Policy attention needs to focus on
supporting people who formerly lived in prisons to access subsidized smoking cessation
pharmacotherapy (101). When these therapies are available and free of charge, they
help to ensure that equivalent care is available upon release and that continued care
is sustained.
In many countries in the WHO European Region legislation banning smoking in public
spaces has been extended to prisons; prison systems are well placed to support the
public health gains inherent in such legislative initiatives (Box 4). Many individuals stop
smoking as a result of entering a smokefree prison, and many European countries now
adopt such policies (102). However, it has been stressed that, for such legislative changes
to be effective, early dialogue between all stakeholders is needed, and whenever there
are concerns – on the part of people living in prisons, staff or both – specific measures
must be adopted to address them (103). Smoking bans are not effective in places where
such measures are not applied, and therefore ex-smokers, following release, should be
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